PROSTHODONTIC SECTION

Complex Occlusal
Rehabilitation: A Case Report
DR. ALI TUNKIWALA

INTRODUCTION Table 1A: Cephalometric Analysis - Vertical Dimension

The most difficult problems in clinical prac- Normal Values Pre Treatment Findings
tice are those where there is interaction of
various pathogenic factors with consequent Posterior Facial Height (S-Gn) 65% 74.3%
complication of therapeutic solutions. Anterior Facial Height (N-Me)
Sometimes the initial situation that the Table 1A indicates that the anterior facial height is reduced as compared to the posterior facial height.
patient presents with is so mutilated that an
end result is difficult to easily visualize. This Table 1B: Cephalometric Analysis - Vertical Dimension
article presents a case report of one such Normal Values Pre Treatment Findings
patient where an organized and comprehen-
sive approach was necessary to have a pre- Lower Anterior Facial Height (ANS - Me) 60% 52.2%
dictably stable long term result with full Anterior Facial Height (N-Me)
mouth rehabilitation. Table 1B indicates that the lower anterior facial height is reduced as compared to the overall anterior
facial height. Thus we can increase the VDO and restore the lower anterior facial height to correct
Full mouth rehabilitation is the reconfigu- proportions.
ration of occlusal and guiding surfaces of
teeth in one or both arches thus achieving a Table 1C: Cephalometric Analysis - Vertical Dimension (Tweed’s Analysis)
physiologic occlusion that allows the muscles
Normal Values Pre Treatment Findings
to function without undue stress and allows
the TMJ to perform its function without any Frankfort - Mandibular Plane Angle 25o 20o
pain or pathology.
Tweed's analysis in Table 1C confirms that the mandible is rotated anti-clockwise and can be turned
clockwise (Vertical Dimension Opened) during the treatment to achieve the desired result.
CHIEF COMPLAINT
A 45 year old female patient reported to our
dental office with severe pain in upper
anterior teeth. She also complained of inabil- problems. The patient had a severe skeletal occlusion with the alveolar ridge in the upper
ity to chew food well and was looking for a deep bite, with multiple posterior teeth miss- left quadrant leaving virtually no space for
solution to her dental maladies (Figures 1-44). ing that had led to a posterior bite collapse. replacing the missing upper left posterior
This further caused the anterior segment in teeth. The clinical findings in the patient
CLINICAL FINDINGS lower arch to impinge on palatal gingiva of have been tabulated in Table 2. To assess the
On examination, it was found that the palatal upper teeth. The clinical examination suitability of various treatment options a lat-
surfaces of upper anterior teeth had moder- revealed that the occlusal plane was deranged eral cephalogram was traced and various
ate recession along with a positive pain severely in both arches as even the upper readings analyzed. All the relevant findings
response to percussion. The lower anterior anterior teeth along with the alveolus were of preoperative lateral cephalometric meas-
teeth were found to be having severe supra supraerupted. The situation was grim on the urements have been tabulated in Tables 1A,
eruption, due to which the upper teeth had left side as the lower premolars were in 1B and 1C.

1 2 3

FIG 4: Pre operative protrusive

FIG 1-3: Pre operative intraoral status guidance

12 DENTAL PRACTICE ' NOVEMBER-DECEMBER 2010 ' VOL 9 NO 6

CLINICAL OPTIONS IN TREATMENT
Table 2
PLANNING
In this patient with complex oral and skeletal Clinical Findings/Signs/Symptoms Treatment (for this case)
problems we require not only a practical Skeletal Class II Not possible
solution, but one that is comfortable and Posterior Bite Collapse Possible
Deranged Occlusal Plane Partly possible
above all esthetically acceptable. Recession on palatal gingiva of 12 - 22 Possible
It was clear that the occlusal vertical Sensitivity Possible
dimension of the patient is lost and needs to Disharmony in gingival levels Possible
be restored. This was complicated by Reduced anterior face height Partly possible
derangement of occlusal plane due to supra-
eruption of anterior segment. The first option
presented to the patient was orthognathic
surgery. This would allow us to reorient the
upper and lower anterior segments and thus
get an acceptable occlusal plane. This option
was declined by the patient. The second
option was to intrude the upper and lower
anterior teeth orthodontically. The lack of
posterior teeth and thus lack of anchorage
FIG 5 FIG 6
was cited as the reason for refusal of ortho-
dontic option by the orthodontist. In current
times orthodontic implants could be used for Table 3 - Treatment Goals are crucial tools to assess where the mandible
anchorage, but in late 2002 that was not an should belong in relation to the upper incisal
option we could consider. The third option Restore comfort edges. It must be understood that using the
Restore lost vertical dimension
was a combined restorative-periodontal rest position of the mandible to arrive at a
of occlusion
approach. We proposed endodontic treat- Replace missing teeth vertical dimension of occlusion is a very
ment for upper and lower anterior teeth fol- Improve esthetics unreliable technique. The rest position has
lowed by crown lengthening surgery with Correct occlusal plane diurnal variations and also depends on the
osteoplasty and full coverage restorations on head position of the patient. At the most it
all existing teeth. The missing teeth could be can be used as a general guideline but freeway
replaced with implants, but economic con- space and its encroachment is not the first
siderations ruled that out. Thus we decided to comfort and helps the patient get rid of severe thing that a dentist must consider in treat-
replace missing teeth with a cast partial den- pain in upper anterior teeth. Endodontic ment planning such cases where vertical
ture in the upper and lower jaw. Table 2 sum- treatment was carried out for teeth 13 through dimension of occlusion is clearly collapsed.
marizes the clinical findings and treatment 22. We now had to decide the tentative verti- Radiographically, the position of the
possibility in this patient. cal dimension of occlusion at which we would condyles in the glenoid fossa can be assessed
restore the patient's occlusion. A bite-raising with a transcranial radiograph. These radi-
FINAL TREATMENT PLAN appliance was fabricated as shown in Figure 5 ographs are taken at close mouth positions
Based on our clinic findings, our final treat- and delivered to the patient. The patient was with and without the bite raising appliance. If
ment plan was to replace all missing teeth instructed to wear the appliance all the time, the condyle has translated too far forward in
with a cast partial denture preceded by full allowing removal only during hygiene proce- the glenoid fossa when the bite-raising appli-
coverage restorations on all existing natural dures. Three weeks are sufficient with such an ance is worn, it means that the vertical
teeth. The contours needed to support the appliance. Thereafter a provisional will be dimension of occlusion may have been
cast partial denture including the rest seats made at the same approved vertical dimen- opened too much, this calls for a reduction in
for the direct retainer were planned in these sion of occlusion and kept in function for the vertical dimension of occlusion. It must
full coverage restorations. Implants were con- another 3 weeks at least. be understood that radiographs are very tech-
sidered to be an option for replacing the At this juncture the findings of cephalo- nique sensitive and dentists must not deter-
missing teeth, but the lack of adequate bone metric analysis, assessment of freeway space mine the final VDO only with help of these
quantity and economic considerations and phonetics were used as a guide to arrive alone. To summarize, all techniques as tabu-
deterred the patient from choosing this at an empirical, working vertical dimension lated in Table 4 are used together to verify the
option. Crown lengthening for all anterior of occlusion. It has to be kept in mind that the vertical dimension of occlusion. The patient
teeth and restoration of lost vertical dimen- vertical dimension should be raised as much perception in these calculations of VDO is a
sion were the prerequisites. as necessary to accommodate the final very important factor.
restorative materials keeping other guidelines The next step was to get the crown length-
CLINICAL PROCEDURES in mind. There are no fixed formula's to ening done for the upper and lower teeth.
Table 3 summarizes the treatment goals we arrive at the vertical dimension of occlusion, The goal here was to reposition the final
set for this patient. but esthetic judgment of upper occlusal plane incisal edges of all anterior teeth in line with
The first step in the treatment restores and phonetic guides (F,V,S,M and E sounds) occlusal plane formed by 14, 15 and 44, 45

DENTAL PRACTICE ' NOVEMBER-DECEMBER 2010 ' VOL 9 NO 6 13

 PROSTHODONTIC SECTION

Table 4: Guidelines to Increase/

Restore Vertical Dimension of
Occlusion
O Cephalometric analysis
O Esthetics
O Phonetics
O Minimum amount required to
accommodate restorative materials
O TMJ X-rays
O Freeway space
FIG 7 FIG 8
O Patient perception of comfort

keeping biological and esthetic guidelines in

mind. The periodontist used this guideline to
decide the level at which the bone should be
adjusted keeping the principles of biologic
FIG 9 FIG 10 FIG 11 width in mind.
At 8 weeks after the crown lengthening
procedure (Figure 6) all teeth were prepared
and impressions taken to fabricate indirect
provisional restorations. Here the patient is
asked to wear the original bite raising appli-
ance first and close the teeth together. A
point is marked on the nose and chin and the
measurements between these will determine
the reading for the vertical dimension of
FIG 12 FIG 13 occlusion. The appliance is then removed
and a wax record taken with the patients jaw
in centric relation at the premeasured verti-
cal dimension of occlusion. Heat cured
acrylic temporary teeth were fabricated and
delivered to the patient. At 4 weeks post pro-
visionalization, a final impression was taken
with polyvinyl siloxane impression material.
A face bow record to orient the upper cast
FIG 14 FIG 15
and centric record at desired vertical dimen-
sion of occlusion were made. The vertical
dimension was maintained at the desired
level by an anterior bite appliance such as the
Lucia jig (Figures 7 and 8). Protrusive record
was made to program the condylar guidance
and right and left lateral records were made
to program the lateral guidance on the artic-
ulator (Figure 9). Wax that becomes dead
soft on heating and rock hard and brittle on
FIG 16 FIG 17 cooling is needed for these records. Any sili-
cone based bite registration materials are
prone to incorporate errors in the bite as
they are not rigid and are better suited for
partial records where vertical dimension of
occlusion is maintained by sufficient num-
ber of intact teeth that provide stable centric
contacts, rather than full arch bite records
such as in this case.
FIG 18 FIG 19 At bisque stage the crowns on all termi-

14 DENTAL PRACTICE ' NOVEMBER-DECEMBER 2010 ' VOL 9 NO 6

nal abutments in each arch were surveyed OCCLUSAL CONCEPTS lesser. Also when the anterior teeth come in
and modified to position undercuts on the For an occlusal scheme to be physiologically contact during protrusion their propriocep-
buccal side at appropriate gingival thirds so acceptable these features are mandatory: tive fibers signal the shutting down of eleva-
that we could have good placement for tor muscle contraction (mainly the masseter,
retentive terminal of the cast partial denture First - Centric occlusion (teeth - teeth rela- medial pterygoid and temporalis). This fur-
(Figure 10). The full coverage restorations tionship in maximum intercuspation) should ther reduces the force on anterior teeth.
on upper anterior teeth were designed in a be in harmony with centric relation ("opti- When developing an occlusal scheme in pro-
way that the lower anterior teeth would have mum joint position independent of teeth trusion the contact between upper and lower
a definite stop on the palatal surfaces of position when the condyles articulate with teeth should be uniformly distributed
upper anterior teeth. This would prevent the thinnest avascular portion of the articular between all incisors if possible.
any further supra eruption of these teeth and disc with the condyle disc complex in superi-
keep the occlusion stable. A few days after or most position in glenoid fossa along the Third - When the mandible is in lateral
cementation of the restorations, impressions distal inclines of articular eminence"). Any excursion the canines only should be in con-
were taken for the cast partial dentures. At 3 interference that deflects the mandible for- tact on the working side thus discluding all
weeks the casting trials and jaw relations ward or laterally from centric relation to remaining teeth in the mouth. The canines
were done. Final cast partial dentures were achieve maximum intercuspation needs to be are the strongest anterior teeth, with stoutest
then finished and delivered to the patient. eliminated when treating the patient. roots having a very sensitive proprioceptive
These cast partials were designed with a load that shuts elevator muscle activity as
broad stress distribution principle. The Second - When the mandible leaves the cen- soon as they are in contact. All these factors,
design is evident in the occlusal pictures of tric relation and goes into protrusive relation, plus their distance away from TMJ helps
stone models (Figures 11 and 12). the anteriors should disclude the posteriors. them to comfortably bear the brunt of lateral
Immediate post operative pictures show This is known as anterior guidance. Anterior occlusion.
the changes made in the vertical dimension teeth are best suited to take load during pro- These principles stated so far are under-
of occlusion and occlusal plane (Figures 13, trusion because of their location is further stood as concepts of Mutually Protected
14, 15). from TMJ and hence the forces on them are (Canine Guided) Occlusion. In some cases

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 PROSTHODONTIC SECTION

Table 5A: Cephalometric Analysis - Vertical Dimension

Normal Values Pre Treatment Post Treatment
Findings Findings
FIG 20 Posterior Facial Height (S-Gn) 65% 74.3% 69%
Anterior Facial Height (N-Me)
Table 5A indicates the increase in anterior facial height as compared to the posterior facial height.

Table 5B: Cephalometric Analysis - Vertical Dimension

Normal Values Pre Treatment Post Treatment
Findings Findings
Lower Anterior Facial Height (ANS - Me) 60% 52.2% 57.4%
Anterior Facial Height (N-Me)
FIG 21
Table 5B indicates the increase in lower anterior facial height as compared to the total anterior facial
height.

Table 5C: Cephalometric Analysis - Vertical Dimension (Tweed’s Analysis)

Normal Values Pre Treatment Post Treatment
Findings Findings
Frankfort - Mandibular Plane Angle 25o 20o 27o
Table 5C indicates the degree by which the mandible has been rotated clockwise to restore the vertical
dimension of occlusion.
FIG 22

the canine itself may be periodontally com- TMJ, muscles, teeth and periodontium to
promised or a missing canine may be work in precise harmony with each other. About the AUTHOR
replaced prosthetically with a bridge or an Various pathogenic factors, iatrogenic caus-
implant. In that case the canine is not suitable es as well as stress can sometimes damage Dr. Ali Tunkiwala,
to take the lateral stresses and it needs help of this fine balance. An attempt is made here completed BDS from
NHDC in 1996, fol-
premolars and sometimes even lateral or cen- to present an insight into the thought
lowed by his Masters
tral incisors on the same side to share the load process that goes in treating such complex Degree in Prosthetic
of lateral occlusion and provide disclusion to cases. The eight year follow up pictures Dentistry from
all the remaining teeth. This is the basic prin- show how most of these concepts do stand Mumbai University
ciple of Group Function Occlusion. the test of time (Figures 19, 20, 21 and 22). (GDC, Mumbai) in
In this patient we provided canine protect- 1998. He has
ed occlusion on the right excursion ACKNOWLEDGEMENTS acquired training in
of mandible and group function on the left as Dr. Sanjeev Patil MDS for the excellent implant placement and restoration at Germany
the left canine was missing and replaced in execution of periodontal therapy and followed by a Fellowship and subsequent
the cast partial denture (Figures 16, crown lengthening principles that have Diplomate status of International Congress of
Oral Implantologist in 2005. He is a Member of
17, 18). proven to be successful by standing true
the American Academy of Cosmetic Dentistry
through this time. and The International Team for Implantologists.
POST OPERATIVE CEPHALOMETRICS Dr. Bhakti Tunkiwala MDS for radiologic He is the Co Director of the ITI Mumbai
The patient was sent for a lateral cephalogram interpretations of transcranial views and Seacoast study club. He has lectured extensive-
to check the post treatment findings. This suitable deduction from them. ly on various aspects of prosthetic dentistry
allows us to evaluate the change we have Dr. Rakesh Kontham MDS for the preop- and implants. Presently he maintains a dental
achieved in the vertical dimension of occlu- erative and post operative cephalometric practice focusing on Prosthetic and Implant
sion and skeletal relations of upper and lower analysis and tracings as well as interpreta- Dentistry in Mumbai and is attached to Saifee
jaw. See Tables 5A, 5B, 5C. tion of various cephalometric findings. Hospital in Mumbai as a consultant. He can be
reached at [email protected].
CONCLUSION Lab support: Dentech Laboratories,
The stomatognathic system requires the Mumbai and Katara Dental, Pune

16 DENTAL PRACTICE ' NOVEMBER-DECEMBER 2010 ' VOL 9 NO 6